In guidance released to state Medicaid agencies, the Trump administration announced January 11 that it would allow states to experiment with creating work requirements for certain recipients of federal Medicaid benefits. In states adopting the guidance, some Medicaid recipients would be required to work in order to stay eligible for benefits.

The 10-page guidance document specifies that the work requirements will not apply to many people with disabilities, as well as pregnant woman, minor children, the elderly and people enrolled in schools, among other subcategories.

Federal Medicaid law already distinguishes between “disabled” and “non-disabled” individuals. People who qualify for Medicaid under the former category, such as Supplemental Security Income (SSI) recipients and people receiving certain forms of institutional care, will be automatically exempt from any work requirements.

For “non-disabled” beneficiaries, the guidance recognizes that certain individuals may nonetheless qualify as having disabilities, and thus be at least partially exempt from work requirements, under the Americans with Disabilities Act and other federal anti-discrimination laws. It also states that people will be exempt if they are “medically frail” or if they are “individuals with acute medical conditions validated by a medical professional that would prevent them from complying with the requirements.”

But beyond this, the authority given to states for determining rules for who must work to retain benefits is very broad. For example, people who are not technically disabled but who are too sick to work may not be exempt from the work requirement; it’s up to the state to decide.

Things are even more confusing for caregivers, who may be on Medicaid themselves because their caregiving duties forced them to quit their jobs. The guidance states that they would be exempt if caring for a “dependent,” but who qualifies as a “dependent” is complicated, especially in the case of adult dependents, where restrictive income rules apply. These rules mean “that many people receiving Social Security benefits, Supplemental Security Income (SSI) or who are themselves on Medicaid may not meet the definition of a dependent,” writes Howard Gleckman, a senior fellow at the Urban-Brookings Tax Policy Center. If the caregiver does qualify for an exemption, she may have to document her caregiving, as is now required in Kentucky, the first state to enact work requirements.

For people with disabilities who aren’t fully exempt from the work requirements, states would have to provide reasonable modifications, such as modifications of hours or additional support services.

People subjected to the work requirements would have to complete 20 hours of work a week to maintain their Medicaid benefits, which could be satisfied by volunteer work, job training, job searching, school, or caretaking, according to the guidance document.

The decision to create the guidance document was prompted by petitions from 10 states to the Department of Health and Human Services (HHS), requesting authorization to create work requirements. Kentucky, via executive orders, enacted work requirements the day after the Trump administration released the guidance. The Southern Poverty Law Center filed a federal class-action lawsuit on January 25 on behalf of 15 Kentucky Medicaid recipients, arguing that by authorizing Kentucky’s new work requirements, the HHS exceeded the scope of its authority under the federal Medicaid Act.

At least nine other states have proposed imposing a work requirement on Medicaid recipients but have not yet received federal approval: Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin.